My objective for GID reform in DSM-5 is harm reduction– depathologizing gender identities, gender expressions or bodies that do not conform to birth-assigned gender stereotypes, while at the same time providing some kind of diagnostic coding for access to medical transition treatment for those who need it. I and others have suggested that diagnostic criteria based on distress and impairment, rather than difference from cultural gender stereotypes, offer a path for forward progress toward these goals. This post is an update to my earlier comments to the APA in June, 2011.

The Gender Dysphoria (GD) criteria proposed by the Sexual and Gender Identity Disorders Work Group for the DSM-5 represent some forward progress on issues of social stigma and barriers to medical transition care, for those who need it. However, they do not go nearly far enough in clarifying that nonconformity to birth-assigned roles and victimization from societal prejudice do not constitute mental pathology. The improvements in the APA proposal so far include a more accurate title, removal of Sexual Orientation Subtyping, rejection of “autogynephilia” subtyping (suggested in the supporting text of the GID category in the DSM-IV-TR), recognition of suprabinary gender identities and expressions, recognition of youth distressed by anticipated pubertal characteristics, and reduced false-positive diagnosis of gender nonconforming children. However, the proposed GD criteria still fall short in serving the needs of transsexual individuals, who need access to medical transition care, or other gender-diverse people who may be ensnared by false-positive diagnosis.

The proposed Gender Dysphoria criteria continue to contradict social and medical transition by mis-characterizing transition itself as symptomatic of mental disorder and obfuscating the distress of gender dysphoria as the problem to be treated. The phrase “a strong desire,” repeated throughout the diagnostic criteria, is particularly problematic, suggesting that desire for relief from the distress of gender dysphoria is, in itself, irrational and mentally defective. This biased wording discourages transition care to relieve distress of gender dysphoria and instead advances gender-conversion psychotherapies intended to suppress the experienced gender identity and enforce birth-assigned roles. The World Professional Association for Transgender Health (WPATH) has stated that, “Such treatment is no longer considered ethical.” (SOC, Ver. 7, 2011)

Transitioned individuals who are highly functional and happy with their lives are forever diagnosable as mentally disordered under flawed criteria that reference characteracterics and assigned roles of natal sex rather than current status. For example, a post-transition adult who is happy in her or his affirmed role, wants to be treated like others of her/his affirmed gender, has typical feelings of those in her/his affirmed gender, and is distressed or unemployed because of external societal prejudice will forever meet criteria A (subcriteria 4, 5 and 6) and B and remain subject to false-positive diagnosis, regardless of how successfully her or his distress of gender dysphoria has been relieved. Once again, the proposed criteria effectively refute the proven efficacy of medical transition care. Political extremists and intolerant insurers, employers, and medical providers will continue to exploit these diagnostic flaws to deny access to transition care for those who need it. The World Professional Association for Transgender Health (WPATH) has affirmed the medical necessity of transition care for the treatment of gender dysphoria. (SOC, Ver. 7, 2011)

The criteria for children are slightly improved over the DSM-IV-TR, in that they can no longer be diagnosed on the basis of gender role nonconformity alone. However, the proposed criteria are unreasonably reliant on gender stereotype nonconformity. Five of eight proposed subcriteria for children are strictly based on gender role nonconformity, with no relevance to the definition of mental disorder. Behaviors and emotions considered ordinary or even exemplary for other (cisgender) children are mis-characterized as pathological for gender variant youth. This sends a harmful message that equates gender variance with sickness. As a consequence, children will continue to be punished, shamed and harmed for nonconformity to assigned birth roles.

A New Distress-based Diagnostic Paradigm.

An international group of mental health and medical clinicians, researchers and scholars, Professionals Concerned With Gender Diagnoses in the DSM, has proposed alternative diagnostic nomenclature based on distress rather than nonconformity (Lev, et al., 2010; Winters and Ehrbar 2010; Ehrbar, Winters and Gorton 2009). These include anatomic dysphoria (painful distress with current physical sex characteristics) as well as social role dysphoria (distress with ascribed or enforced social gender roles that are incongruent with one’s inner experienced gender identity) For children and adolescents, these alternative criteria include distress with anticipated physical sex characteristics that would result if the youth were forced to endure pubertal development associated with natal sex. For those who require a post-transition diagnostic coding for continued access to hormonal therapy, the criteria include sex hormone status. Psychologist Anne Vitale (2010) has previously described this distress as deprivation of characteristics that are congruent with inner experienced gender identity, in addition to distress caused directly by characteristics that are incongruent.

Building on this prior work, I propose that gender role component of gender dysphoria, including distress with a current incongruent social gender role and distress with deprivation of congruent social gender expression, can be more concisely described as impairment of social function in a role congruent with a person’s experienced gender identity. I believe it is also important to include other important life functions, such as sexual function in a congruent
gender role. This language would provide a clearer understanding of the necessity of social and medical transition for those who need them.

These alternative criteria acknowledge that experienced gender identity may include elements of masculinity, femininity, both or neither and are not limited to binary gender stereotypes. They also define clinically significant distress and impairment to include barriers to functioning in one’s experienced congruent gender role and exclude victimization by social prejudice and discrimination.

Suggested Diagnostic Criteria for Gender Dysphoria in the DSM-5

I would like to suggest the following diagnostic criteria for the Gender Dysphoria for adults/adolescents and children–

A. Distress or impairment in life functioning caused by incongruence between persistent experienced gender identity and current physical sex characteristics in adults or adolescents who have reached the earlier of age 13 or Tanner Stage II of pubertal development, or with assigned gender role in children, manifested by at least one of the following indicators for a duration of at least 3 months. Incongruence, for this purpose, does not mean gender expression that is nonconforming to social stereotypes of assigned gender role or natal sex. Experienced gender identities may include alternative gender identities beyond binary stereotypes.

A1. Distress or discomfort with one’s current primary or secondary sex characteristics,
including sex hormone status for adolescents and adults, that are incongruent with
experienced gender identity, or with anticipated pubertal development associated with
natal sex.
A2. Distress or discomfort caused by deprivation of primary or secondary sex
characteristics, including sex hormone status, that are congruent with experienced
gender identity.
A3. Impairment in life functioning, including social and sexual functioning, in a role
congruent with experienced gender identity.

B. Distress, discomfort or impairment is clinically significant. Distress, discomfort or
impairment due to external prejudice or discrimination is not a basis for diagnosis.